Georgia, known as the “Peach State”, has a diverse and growing population, robust political landscape, and a slow growing health care environment. The distinct health care environments in rural Georgia and the urban metropolitan area are a unique challenge for the Title V MCH Program. The growing population amplifies challenges that arise from the political landscape, health care environment, economy and/or sociocultural context.

 

Geographic Description
Georgia is located on the southeastern Atlantic coast of the United States whose terrain spans coastal beaches, farmland, and mountains. It is bordered on the south by Florida; on the east by the Atlantic Ocean and South Carolina; on the west by Alabama; and on the north by Tennessee and North Carolina. The highest point in Georgia is 4,784 feet; the lowest point is sea level. Georgia is ranked 24th in terms of land size and is the largest state geographically east of the Mississippi River.

 

Urban and Rural Counties
Of Georgia’s 159 counties, there are both urban and rural located throughout the state. The Census Bureau defines two types of urban areas: urbanized areas of 50,000 people or more, and urban clusters between 2,500 people and 50,000 people. All other counties are considered rural. Of the 159 counties in Georgia, 124 are designated as rural by the Georgia Rural Development Council. There are 20 smaller cities and urban areas with populations above 50,000. Most the state’s rural counties are in the southern half of the state. 

 

According to the 2010 census, the most recent census available, there are 15 Metropolitan Statistical Areas in Georgia: Albany, Athens-Clarke County, Atlanta-Sandy Springs-Roswell, Augusta-Richmond County (GA-SC), Brunswick, Chattanooga (TN-GA), Columbus (GA-AL), Dalton, Gainesville, Hinesville, Macon, Rome, Savannah, Valdosta and Warner-Robins. 4 The largely rural makeup of the state provides many challenges, and opportunities, to offering adequate health and social services to all Georgia residents. Due to the large number of counties being designated as rural, access to health care services is challenging, and as such it is essential for DPH to accommodate the needs of the rural population. DPH provides an alternative approach in meeting the needs of Georgia’s rural citizens through innovative strategies such as telehealth services that increase access to health care providers and services. The following map generated by the US Census Bureau based on population data for 2010 depicts the urbanized and non-urbanized areas in Georgia.

 

Figure 1: Urbanized areas in Georgia

 

 

Population
According to July 2019 population estimates from the US Census Bureau, Georgia is the eighth most populous state in the nation with an estimated population of 10,617,423.38 Since 2000, Georgia’s population has increased 25 percent with the population first surpassing 10 million residents in 2013. This growth has resulted in a fundamental shift in Georgia’s population changing the state from a largely rural area with urban centers to an urban state with rural areas. Rural Georgians have health experiences that contrast their urban counterparts including, travelling longer distances to seek medical care and higher rates of chronic health conditions.18 Georgia is the 14th fastest growing state in the nation and is the 7th highest among states with the largest numeric population increase.17 It is estimated that Georgia’s population will increase to 11.8 million by 2030.10 As with any population growth, there are increasing demands on state and local governments to provide necessary services, including health and social services.

 

Atlanta, the state capitol, is the economic, cultural and demographic center of Georgia. The Atlanta metropolitan area, which includes 29 counties, had the nation’s fourth highest population growth from 2017 to 2018 with an estimated population of more than 5.9 million. Metro-Atlanta contains about 57 percent of Georgia's entire population.39 Approximately 6.2 percent of residents are under age five, 23.8 percent are under the age of 18 and 13.9 percent are over age 65. Females comprise 51.4 percent of Georgia’s population. Georgia has the second-highest LGBTQ percentage in the South with a population of roughly 4.5 percent and ranks 17th nationwide. An estimated 4.2 percent of Atlanta’s metropolitan population is gay, lesbian, or bisexual.40

 

Georgia has shown dramatic increases in minority groups, which account for approximately 47 percent of the overall state’s population. This trend in the demographic shift is expected to be sustained in the coming years and Georgia is projected to become a majority-minority state by 2028.53 Currently, Black or African American is approximately one-third of the state’s overall population and the largest minority group; this is approximately 2.5 times higher than the national average of 13 percent. Hispanic or Latino is the most rapidly growing minority group, comprising almost 10 percent of all Georgians. Persons of Asian descent are an additional four percent of the state’s population.

 

Race/Ethnicity
In 2019, the US Census Quick Facts illustrated that 60.2 percent of Georgians were White, 32.6 percent were Black or African American, 9.9 percent were Hispanic or Latino, and 4.4 percent were Asian.42 The number of Hispanics in Georgia doubled between 2000 and 2010, according to the most recent U.S. Census. The number of Asians nearly doubled, with the highest increases seen among Asian Indian, Korean and Vietnamese populations. Such a growth in diversity and population necessitates the availability of culturally competent health care, education and human services.18

 

Age and Gender
According to the US Census Bureau estimates in 2019, Georgia’s population is younger compared to the U.S., with the 8th largest percent of population under 18 years old (23.6 percent). The median age in Georgia is 36.2 years of age, with a gender difference of 51.3 percent females and 48.7 percent males across the state. There are approximately 2.1 million Georgian women of reproductive ages (15-44 years old). In 2019, there were 126,250 births in Georgia.42

 

Immigration
Georgia’s population is continually evolving with the immigration of foreign-born individuals that add to the racially and ethnically diverse population of Georgia. In 2019, it was estimated that one in ten Georgia residents is an immigrant, while seven percent of residents are native-born U.S. citizens with at least one immigrant parent. However, there has been an increase in naturalized citizens from 33.8 percent in 2010 to 43.6 percent in 2018.19 In 2018, 1.1 million immigrants (foreign-born individuals) comprised 10 percent of the population. Georgia was home to 502,347 women, 493,737 men, and 67,989 children who were immigrants. The top countries of origin for immigrants were Mexico (22 percent), India (nine percent), Jamaica (four percent), Korea (four percent), and Guatemala (four percent).19

 

Immigrants in Georgia are concentrated at either end of the educational spectrum. More than a third (35 percent) of adult immigrants had a college degree or more education in 2019, while one-quarter (25 percent) had less than a high school diploma. In 2019, 23.2 percent of foreign-born residents had a high school diploma or GED with 16.9 percent attaining some college or their associate degree.19 In 2019, 38.2 percent of foreign-born residents fell below 200 percent of the poverty level and 31.3 percent had no health insurance coverage.19

 

Language Proficiency
Over 13 percent of Georgia residents speak a language other than English.19 Of the other languages spoken; Spanish is the most commonly spoken language at approximately 8 percent. Both other Indo-European languages, Asian and Pacific Island languages, account for approximately 2.5 percent, and the remaining 1 percent of residents speaks another language. Of those that speak a language other than English, 43 percent speak English less than very well.19 These factors can have implications on the services offered to residents and may necessitate investment in interpretation and culturally competent approaches to health care delivery.

 

Family Household Type

Children growing up in single-parent families typically do not have the same economic or human resources available as those growing up in two-parent families. Compared with children in married-couple families, children raised in single-parent households are more likely to drop out of school, to have or cause a teen pregnancy and to experience a divorce in adulthood. In 2017, according to the 2019 Kids Count data, 38 percent of Georgia’s children lived in single-parent families. Children living in high-poverty areas decreased from 14 percent in 2012 to 13 percent in 2017.45 The average household size was 2.6 and the average family size was 3.2.16

 

Educational Attainment
Public schools are the primary source of education in Georgia. In 2017, 64.6 percent of children attended a public nursery school and/or preschool while 35.4 percent attended a private nursery school and/or preschool. In 2017, 90.5 percent of students in Kindergarten to 12th grade were in public school and 9.5 percent were in private school.19 According to the 2019 Kids Count Data, young children, ages three and four, not in a preschool program has remained at 50 percent over the past ten years. Fourth graders proficient in reading improved from 29 percent in 2009 to 35 percent in 2017. Eighth graders not proficient in math improved from 73 percent in 2009 to 69 percent in 2017 and high school students not graduating on time reduced to 19 percent in 2017 from 33 percent in 2011.55

 

Georgia's graduation rate continues to rise. The rate has increased by 12 percentage points since 2012. In 2019, Georgia's high school graduation rate increased, rising to 82 percent, an all-time high since the state began using the adjusted cohort calculation now required by federal law.55

 

Large racial and ethnic difference exist in postsecondary educational attainment in Georgia. About four in ten Georgians older than 25 have an associate or bachelor’s degree. The share is closer to two in ten for Latino Georgians and three in 10 for African Americans. About six in ten Asian American and Pacific Islanders have an associate degree or above, the highest rate of attainment of any racial or ethnic group.56

 

According to the American Community Survey (ACS) of the U.S. Census Bureau, the median household income for Georgia was $55,679 in 2018, the latest figures available. Compared to the median U.S. household income, Georgia’s median household income is $4,614 lower.18

 

Table 2. Median Household Income in Georgia and the US, 2008-2018

Year	Georgia	United States
2018	$55,679	$60,293
2017	$52,977	$57,652
2016	$51,037	$55,322
2015	$49,620	$53,889
2014	$49,342	$53,482
2013	$47,829	$52,250
2012	$47,895	$52,117
2011	$47,650	$52,306
2010	$49,605	$53,469
2009	$51,684	$54,541
2008	$55,027	$56,290

 

Poverty
Poverty is more prevalent in Georgia than in many states across the nation. According to the latest available data, in 2018, 14.3 percent of Georgians were living below the poverty line, compared with 11.8 percent for the U.S. overall. Over eight percent were below 50 percent of the federal poverty level (FPL) and 22.9 percent were living at less than 125 percent of the FPL. As of 2018, twenty-one percent of children in Georgia under the age of 18 live in poverty, which is an improvement from 25 percent in 2010. Poverty disproportionately affects race and ethnicity in Georgia. The poverty of Georgians living below the FPL based on race and ethnicity in 2018 was 20 percent, with 11 percent White, 29 percent African American or Black, 8 percent Asian and Pacific Islander, and 30 percent Hispanic or Latino.19

 

Health Equity and Social Determinates of Health (SDoH) Disparities

According to the 2019 Kids Count Data Book, Georgia ranked 39th in overall child well-being, 37th in economic well-being, 39th in health, 40th in family and community, and 34th in education. The annual Kids Count Data Book uses 16 indicators to rank each state across four domains – health, education, economic well-being and family and community – that represent what children need the most to thrive. Though Georgia’s children and families still face many challenges, there are some promising trends for the state. When looking at outcomes such as maternal mortality, infant mortality, low birth weight, and preterm birth we see consistent trends based on race/ethnicity. Georgia’s maternal mortality rate illustrates that Black, non-Hispanic women are three times more likely to die of pregnancy-related complications than White, non-Hispanic women. In 2018, racial disparities were also seen in infant mortality rates with a rate of 11.8 in Black, non-Hispanic or Latino infant deaths compared to a rate of 5.0 in White, non-Hispanic or Latino infant deaths under one year of age. The percent for Black, non-Hispanic or Latino low birth weight infants was 14.7 percent compared to 7.2 percent for low birth weight White, non-Hispanic infants. Premature births in 2019 occurred at 14.7 percent in Black, non-Hispanic women compared to 10.0 percent in White, non-Hispanic women.57

 

Economy

A vital component to Georgia’s economy is the transportation system including the interstate highway system, Hartsfield-Jackson Atlanta International Airport, and the deep-water ports of Savannah and Brunswick.

 

Georgia has over 1200 miles of interstate highways which connect Georgia to neighboring states and the rest of the nation and help move workers from their homes to places of employment in the major cities. Three of the interstate highways converge in Atlanta, making it, along with Hartsfield-Jackson Atlanta International Airport, the transportation hub of the southeast. Atlanta is one of only five cities in the nation to be served by three separate interstate highways. The construction of these interstate highways was instrumental in the booming growth of Atlanta in the latter part of the 20th century. The highways helped attract business, industry, and more transportation facilities to the Atlanta area.39 These advantages have led to many global headquarters establishing headquarters in Atlanta including 16 Fortune 500 companies, 26 Fortune 1000 businesses and more than 450 Fortune 500 companies having a presence in the state.42

 

Georgia economic products can now reach approximately 80 percent of Americans overnight using the interstate highway system, while products coming into Georgia can reach Georgians in every part of the state just as quickly.

 

Two of the interstate highways- I-85 and I-285- are near Hartsfield-Jackson Atlanta International Airport. Hartfield-Jackson is one of the busiest airports in the nation. Business travelers and those visiting Georgia add enormous impact to Georgia’s economy. Hartfield-Jackson also hosts the only Perishables Complex in the southeast- allowing for rapid movement of agricultural products. In addition, Hartsfield-Jackson is home to the Georgia Foreign Trade Zone, where Georgia companies can produce products at reduced cost, facilitating trade and increasing the overall competitiveness of companies doing business in Georgia. Combining all aspects of Hartfield-Jackson’s effect on the regional economy of Atlanta, Georgia, and the southeast, it generates $23.5 billion on an annual basis. The deep-water seaports of Savannah and Brunswick are integral to Georgia’s economy as they allow products to be sent via ship to all parts of the world, while allowing foreign products to come into Georgia. The port of Savannah handles approximately 80 percent of the material entering Georgia via ship and is one of the fastest growing ports in the nation. 39

 

The film and television industry are other major industries adding to Georgia’s economy. Georgia offers lucrative tax incentives for television and movies making the state a popular site for filming and production stimulating further growth. A little more than a decade ago, the state passed a tax credit that allowed productions to collect a credit of up to 30 percent of its budget, enabling studios to save money or increase their budgets. Producers also prefer the state’s generally lower prices compared with California or New York, as well as the geographic diversity with cities such as Atlanta and many rural locations which offer a variety of settings. Georgia's film industry has continued to grow with 399 productions from July 1, 2018 to June 30, 20198 filmed in Georgia resulting in a record $2.9 billion invested in the state.63 Film and television production in Georgia support more than 92,000 jobs and brings significant economic benefits to communities and families. Georgia had 455 qualified television and film production in 2018.48

 

Georgia has a rich, varied, and ongoing tradition of producing quality sports teams that enhance the economy. Atlanta is home to six professional sports franchises- the Braves (Major League Baseball), Hawks (National Basketball Association), Falcons (National Football League), Dream (Women’s National Basketball Association), Atlanta United (Major League Soccer) and the recently added Big Peach (Major League Rugby).47 Atlanta was home to NFL Superbowl LIII with more than 500,000 attending and more than 150,000 out-of-state visitors.47 In addition to Atlanta’s major league sports teams, minor league franchises are hosted by several Georgia cities. Augusta, Georgia is home to the Masters, professional golf’s most famous and prestigious event. Atlanta Motor Speedway hosts one of NASCAR’s biggest races each Labor Day weekend. Sports provide an economic boost for the city and remain a key revenue-generator within the tourism industry.41

 

Homelessness

In 2019 a total of 4,183 people in 152 counties (not including Atlanta), covering 96 percent of Georgia’s geography, met the Housing and Urban Development’s (HUD) definition for homelessness, a 13 percent increase from 2017. Fifty-four percent were unsheltered; the other 46 percent were in emergency or transitional housing. A larger percentage of homeless families were sheltered, 92 percent, than unsheltered, and a larger proportion of individuals without children were unsheltered,73 percent, than sheltered. Child Only households represented less than one percent of the homeless population. Six percent of the estimated homeless population identified as veterans and seven percent identified as chronically homeless, defined as having a disability and length of homelessness of at least one year or experienced homelessness four times in the past three years. Domestic violence victims, mental illness, and substance abuse disorder were among the greatest populations represented.58

 

The homeless youth population, youth under the age of 24 with or without a child under the age of 18, represented eight percent of the total homeless population.59 Also, in 2019, the city of Atlanta reported 3,217 homeless, a 4.5 percent overall increase from 2017. A total of 84.3 percent were over the age of 24.60

 

Insurance Status
Georgia’s uninsured population rate rose slightly in 2019 to 13.7 percent giving Georgia the third-highest percentage of uninsured in the U.S. In 2018, there were 19.4 percent of women ages 15-44 uninsured in Georgia.61 Six percent of Georgia’s children are uninsured, making it the state with the 9th highest rate of uninsured children. The most recent data available show that among Georgians between 19 to 64, 19 percent are uninsured, ranking it the fourth highest in the nation.11 Those that identify as Black and White have the highest percentage of being uninsured, 40 percent and 34 percent, respectively. Twenty-one percent of Hispanics are uninsured.11 This is yet another disparity that further contributes to the delay in seeking health care, increased visits to the emergency room and poor health outcomes.

 

Medicaid provides nearly two million Georgians with vital health services, 92 percent of whom are children, elderly or disabled. Medicaid covers 1.3 million Georgia children and Georgians who live with disabilities. 62

 

Health Reform
The Affordable Care Act, signed in 2010, went into effect in 2014. It is a state decision to participate in the Medicaid expansion or not, and as of 2019 Georgia will not expand. More than 460,000 people enrolled in plans for 2019 during open enrollment, a drop of more than 20,000 from 2018.3 Four insurers offer coverage in 2019 through Healthcare.gov. Average rate increases for plans in Georgia’s individual market are less than four percent for 2019.3 DPH will continue to adapt to the changing health care landscape to promote the health of women and children.

 

Title V Priorities

Considering the geographic and demographic landscape in Georgia, this is a critical time for the Title V program to set priorities. The process used by the Title V Director, MCH Staff, partners and stakeholders for determining the needs and priorities of the program is multifactorial. The five-year needs assessment is used to evaluate priorities and efforts are made to align with priorities of the Governor, Commissioner and Executive Leadership representing the MCH section within the agency. Title V priorities are also chosen to the extent that they address needs that are not otherwise met through other grants, programs and partnering organizations.

 

The mission of the Department of Public Health is to prevent disease, injury and disability; promote health and wellbeing; and prepare for and respond to disasters. DPH’s workforce is guided by the following core values in carrying out our public health work:

 

People – We value our employees as professional colleagues. We treat our customers, clients, partners, and those we serve with respect by listening, understanding and responding to needs.

 

Excellence – Commitment, accountability, and transparency for optimal efficient, effective, and responsive performance.

 

Partnership – Internal and external teamwork to solve problems, make decisions, and achieve common goals.

 

Innovation – New approaches and progressive solutions to problems. Embracing change and accepting reasonable risk.

 

Science – The application of the best available research, data and analysis leading to improved outcomes.

 

DPH COVID-19 Response

DPH is working closely with the CDC, and state partners to respond to the COVID-19 pandemic. The goal is to quickly identify cases of COVID-19 and take the appropriate public health action to reduce its spread and protect the general public.

 

DPH Emergency Preparedness and Response (EPR) is providing CDC information and guidance about COVID-19 to all health care and hospital facilities throughout Georgia and holding weekly calls with the entire public health and hospital/health care community to update information and answer questions. DPH serves as the clearinghouse for coordination between state agencies, health care providers and medical facilities and has created communication strategies for presenting CDC messages such as billboards, Public Service Announcements (PSA), flyers and videos. DPH is poised to provide infrastructural and leadership support to improve the health of mothers, children, and families. MCH Title V programs have continued to implement evidence-based approaches to address COVID-19. MCH programs share COVID-19 messaging with district staff, partners and families and have adapted policies, procedures, and ensured continuity of care for home visiting programs, early intervention, child health services, and CYSHCN services. MCH programs have developed innovative strategies utilizing telehealth that have enabled continuity of care in providing home visiting and early intervention services. Expanding telehealth services to traditional in person service delivery programs have allowed for an opportunity to ensure that families receive vital support while following COVID-19 prevention guidelines.

 

DPH epidemiologists are on-call to help health care providers evaluate individuals presenting with symptoms of COVID-19 to ensure that possible cases are managed safely, support laboratory testing and implement recommendations from the CDC. In the event of COVID-19 in Georgia, epidemiologists would also be monitoring outbreaks and recommending control strategies, including guidance regarding testing and isolation.

Should it become necessary, DPH may recommend appropriate community mitigation measures for affected communities, such as temporary closure of childcare facilities and schools/colleges and universities, school and workplace social distancing measures, and postponement or cancellation of mass gatherings. Additionally, businesses should consider ways to implement strategies to reduce the impact of a potential COVID-19 outbreak on their workforce, including teleworking and cross-training employees on essential job functions.

 

COVID-19 is rapidly evolving, and guidance is subject to change. The preparations currently underway in Georgia are based on the best scientific information and data from the CDC. DPH continues to monitor the COVID-19 situation, and work with state partners and health care communities to incorporate the most up to date guidance in our planning and preparation efforts.

 

Healthy Georgia Collaborative

Healthy Georgia Collaborative is Georgia’s COVID-19 contact tracing initiative executed by DPH. Contact tracing is the process of quickly identifying, assessing, and managing people who have been exposed to a disease to prevent additional transmission. When used with other public health measures like widespread testing and social distancing, contact tracing is a key strategy for preventing further spread of COVID-19. DPH has trained a large contact tracing workforce exceeding 1,450 employees to stop the transmission of COVID-19. DPH maintains long-standing relationships with many of Georgia’s colleges and universities, and these relationships are more important than ever in the fight against COVID-19. Leveraging our existing partnerships, DPH’s University Relations/ Applied Learning Program screened over 2,000 internship applications and recruited 284 interns from Georgia schools for the Summer 2020 Contact Tracing internship. In addition to actively recruiting students for Fall 2020 internships, University Relations is also working to expand our partnership network to additional Georgia universities and technical colleges, particularly those in the state’s rural regions.